PAC 799B Module 6 Chapter 5: Discussion and Implications Example

Chapter 5: Why a Packed Bag Changed the Answer

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 799B: Addiction Studies Capstone

Instructor Name

Month Day, Year

Chapter 5: Why a Packed Bag Changed the Answer

Summary of Findings

At Pine Hollow, the imaginary Georgia county jail of this capstone, fewer than two in five people with opioid use histories left with a naloxone kit under the opt-in offer. Uptake was lowest at night and among people released from court. People described the release desk as a place where a kit could only be accepted in full view of officers, and night and court releases as too rushed for the offer to register. After kits were packed by default, about four in five left with one, the change appeared at once and lasted through the follow-up, while the night gap almost closed. About one in five still declined.

Why the Default Worked

Johnson and Goldstein (2003) proposed three reasons that defaults change choices: they require no effort, they may be read as a recommendation and they spare people an active decision. Each appeared in what people said. The effort of asking for or agreeing to a kit was removed; it was simply in the bag. Several people described the packed kit as a sign that the jail expected them to have it, a form of implied recommendation. And the theme "not in front of them" points to the third reason: under opt-in, accepting a kit required a public act that felt like a confession, while under opt-out, keeping the kit required nothing. The near-closing of the night gap fits the same account. At night, when releases were rushed and the offer barely heard, the default did not depend on a conversation that had no time to happen.

Why Uptake Matters

The project measured uptake, not deaths, and cannot show that the change saved lives. But the literature suggests why uptake matters. Binswanger et al. (2007) showed the extraordinary overdose risk in the first weeks after release. McDonald and Strang (2016) judged that putting naloxone in the hands of people at risk lowers the death toll from overdose. Walley et al. (2013) found that communities where naloxone programs enrolled more people had larger reductions in overdose death rates, suggesting that reach is part of what makes such programs work. Bird et al. (2016) add that after Scotland began supplying naloxone at prison release, the proportion of opioid deaths that happened in the month after leaving prison went down. Doubling the share of people who leave Pine Hollow with a kit increases exactly the kind of reach these studies associate with fewer deaths, though whether it does so here remains to be shown.

The People Who Still Declined

About one in five people still left the kit at the desk. Their reasons, fear of being stopped by police with it and not wanting a record of taking it, differ from the reasons people declined under opt-in. Under opt-in, many seem not to have engaged with the offer at all; under opt-out, those who declined made an active choice, often from fear of consequences. This suggests the default captured people who were indifferent or embarrassed, while those with specific fears remained. Addressing those fears requires something other than a default: clear information that carrying naloxone is legal, perhaps printed on the kit, and offering kits through the peer organization after release for people who prefer not to carry one out of the jail.

Comparison With Expectations

Chapter 2 noted that most evidence on naloxone at release counts kits distributed and that no study had tested an opt-out offer in custody. The size of the change, about 43 points, is large compared with many health interventions, but consistent with the large default effects Johnson and Goldstein reported. The absence of any gradual trend after the switch, a step rather than a slope, also fits a default effect, which acts at once rather than building over time as a training or awareness effort might.

The Researcher's Position

As a case manager at the jail, Avery hoped the change would work, and that hope could have shaped the reading of interviews. Two safeguards limited this. The reflexive journal recorded expectations before the analysis began, including a prediction that uptake would reach about 60 percent, well below what occurred. And the peer mentor's review of the themes came from someone outside the jail. The size of the change surprised Avery, which is some evidence that the result was not read into the data.

Implications for Practice

For Pine Hollow, the findings support keeping the opt-out offer as standard and preserving the steps that made it work: the eligibility flag, the daily release list for court releases and the property room checklist. For release desk staff, the script matters; a neutral statement that the kit is in the bag avoided the confession that the old offer required. For re-entry staff, the people who still decline should be offered a kit by the peer organization after release.

Implications for Policy

For the county health department and jail administrator, the findings support a written policy making opt-out naloxone standard at release, with a guaranteed supply, since a three-day shortage interrupted delivery. Other jails in the state could adopt the same procedure at low cost.

How the Findings Fit the Corrections Literature

The findings also sit alongside the broader evidence that action inside correctional settings can change what happens after release. The studies reviewed in Chapter 2 concerned whole systems, a national program or a statewide jail and prison system, while this project concerned one release desk. That difference in scale is a reminder that small procedural details, such as where a kit is placed and what a nurse says, may decide whether a policy ever touches the people it was written to protect. Large programs are built from many such desks.

Implications for Research

Future research should follow what happens to kits after release, whether they are carried, given to family or used, and should link release records to overdose outcomes in larger systems where numbers allow. Research should also test ways to reach the people who decline even under opt-out.

Conclusion

The opt-out offer changed the answer because it changed the question people faced at the release desk, from a public choice to accept to a private choice to refuse. The result fits Johnson and Goldstein's account of defaults, and the literature on naloxone reach and release suggests why it matters. The people who still declined point to the next step.

References

Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J. G., & Koepsell, T. D. (2007). Release from prison: A high risk of death for former inmates. New England Journal of Medicine, 356(2), 157-165. https://doi.org/10.1056/NEJMsa064115

Bird, S. M., McAuley, A., Perry, S., & Hunter, C. (2016). Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: A before (2006-10) versus after (2011-13) comparison. Addiction, 111(5), 883-891. https://doi.org/10.1111/add.13265

Johnson, E. J., & Goldstein, D. (2003). Do defaults save lives? Science, 302(5649), 1338-1339. https://doi.org/10.1126/science.1091721

McDonald, R., & Strang, J. (2016). Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction, 111(7), 1177-1187. https://doi.org/10.1111/add.13326

Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, Article f174. https://doi.org/10.1136/bmj.f174